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HomeMy WebLinkAbout14172 (17) �,\ CITY OF DIAMOND BAR f �` DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES / �� . 21660 E.Copley Drive Suitc 190 (909)860-3195 Fax(909)861-31 I7 PRESS ������ BUILDII�G PERMYT APPLICATION � FIRMLY . .... . .... . . _ ., QJOBSITE ��3 �� ���il�l.t� ��+�...,. DAPEICA710N •�� ����U 8 R__�•��#/�.� �"J_ "��, Q ADDRESS ( /�� � APN LOT � TRACT � � ISSUE TYPE OCC DATE_ CONST. GROUP p OWNER �'°�0 - �—l�a��,���' _ ADDRESS�' � � ��'' ' ZONING SET8ACK5 W CITY I�lp��"ND�O L�'1�7� ZIP TEL. E = �� FRONT _ _ RW C � APPLICANT _,"P�lk�'T�`1 C..��L. REAR � �— �--'� SIDEiSiDE STREET RW C______ � CONTRACTOR 'I� �f Ly�ti, .r � SIDE ,__ _]__ p� ADDRESS �?'�--��--'� M, pROPOSED USE��� �'��I G� ���I� _�v G�G�- o crrv Cp rrid ,�14.►��_ ziP r�.�1 TEL� -- �?� ,� w ARCHlENG/ � r /d -- � DESIGNER_N/� NO.DWEL. NO. NO. �y ADDRESS�_ .— � UNITS____ STORtES BEDROOMS � CITY ZIP__ TEL.__ � — QESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION Q OWNER-BUILDER DECLAFlATION SFRlADD/REM O ----r-- I HEREBV AFFIRIA UNDER P�rypLTY OF PERJURV THAT I AM I:XEie9PT FROM�Hf CONTRACTOqS L!- GefegO/C8ry0fI W CENSEUWFOfliHEFOLLOWMGREA30N(SEC,7037.SBUSINESSANDPROFESSIONSCODE:ANYCITYOR � U COUNTYWHICHREdIIRESAPERMITTOCANSTRUC7.JLLTEF,IMARCVE,�EMOLISH.ORREPA�RANVSTRUC- •patio!DeCk '� � w IURE,PRIOR TO ITS ISSUNJCE,ALSO REOUIRES hiE APPUCANT FOR SUCH PERIAIT TO FILE A S�ONED � STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE P%OVISIONS OF THE CONTRACTORS LI- C CENSE LAW ICHAPTER 9 f���ENCINO WITH SEC710N 7000)OF D�VISION 3 OF THE BUSINESS ANO PRO- POOI/Spa_ 9E FESSbN5CO0E)ORTHATHEORSHEISEXEIAPTTHEREFRqAANCTHEBASISFORTFIEALLEGEDEXEMP- (� U TION.ANYVIOLATIONOFSECTION7a31.5BVAMYAPPLICAN7FORA7ERMITSUflJECTSTHEAPPLICANTTO Z RB-P.00f � ACIVIL PENPLTY OF NOT MORE THAN FIVE HUN�RED UOI.L4R5(5500).J: � ❑I,M40WNEROFTHFPROPERN,ORMYEMPLOYEESWITHWAOESASTHEIRSOiECANPENSATION, Q COnl111BfCi81 WIIL UO TNE WORK,AND THE STHUCTURE IS NOT IMENDED OR OFFERED FOR SALE 1SEC.70ad,61151� J � NE^aS AND PiiOFESSIONS CO�E:THE CONiP.ACTORS LICENSE LAW�ES NOT APPL\'TO AY OWNER OF ? AROPERTY NRp BUIlOSOF IMPqOYES THEREOk,AND VdMO OOES SULH WORK HIMSFLFOF HERSE!F OR QC THROIJ(iHHISORHEROWNEMPLOYEES,PROVIDWTHAT5UCH1E4�qOVEMENTSAREN0T6YTEN�EDOR � QOFFEqE�FOfiSILLE.IF,HOWEVER,THE6NLDINGORIIAPROVEY.EN71S501DWITHINONEVEAROFCOMPLE _ .,'�` Z TION,TFIE OWNEH�BUILDEF NfiLL HAVE THE BURDEN OF PROYINC iH11 MF.OR SHE DID NOT BUILD OR -' y � = IMPHOVEFORTHEPLIRPOSEOFSALE). "� . '�i •' L'I.ASOWNEROFTHEAROPER'TV,AMEXCLUSIVELY(:ON'RHCTiNGW17HLICENSE�CONTRACTORS 't, TO CqNSTRUCT THE PR0.IECT(SEC.70S4,BUSINE55 AND PROFFSSIONS CODE:THE CONTRAC70qS U- V81u3tiOf: - ,r_x P.DJ.AREA_._,_ W CENSELAWDOESNOTAPPLYTOANOWNEAOFAPROPERT'WMOBUIIOSORIMPROVFSTHEPEON,qND - --- Z 1YF1000NTRACTSKORSUqiPR0.lECT5WITHACANTRACTOR�S)I.ICF.45EOPURSUANTTOTHECONTRAG � •QURNTITY DES�F3IPTION FEE F- TOR5LICENSELAW.). ' �e� Q � J � ❑10.M EX£MPTUiJDER SEC._ ___,__._.__B.&P.�.Fpq TH;S REASO�i ' Q _ � ------------- ` �� I . lJ' DATE___- OWNER--_'-_'__ "_- ,�_'� IU _' -- - .Z �-� _ _'� w �$ LICBNSED CONTRACTORS DECLARATION = W _� [� IHEREBYAFFIRMUNDERPENA�iYOFPERJURVTHA7IAMLIC[NSEDUNOEFPROVISIONSOFCHpPTE9 i � d 9�COMMENCINGW17HSECTIDN7oC0)OFOIV;SION30F7HE9USINESSANDPROFESSICNSCOOF.A'i0 � Z X MY UCENSE IS M NI.L FORCEAND EFFECT. ..�f U..! � 1� A � —�-- A LICENSEC4ASS ►,'���,.��� LIC.NO._ � � F �ATE��S��.._laZ.iL�_ CONTRACT6R._ �` JI �� U _' -_' '_'.— . iU +� ,y � � f.�1�-"'�, � WO�iKERS'COMPENSATION DECL?.RATIOPJ �-r�(3 �j�y���a � ,`�.. U -- � I HEREBY AFFIRM UNOER PENALTV OF?ERIIIRY ONE OF'HE FOi!.OWING DECUIRATIONS: ;� � __IHAVEAN�WILLMAINTAINACERTIFICRTE�FCONSENTTOSELF-I"1SUREFORWOFKERS' _ -_ �' GOMPENSATIOM,AS PROVIUED BV SECTION 370o OF TIIF.UBOq COC7E,FOR THF.PER�ORMANCF `U OF THE WOFlK FOR WHICH THIS PERMIT IS ISSUED. ` � --_ � _I HA9E ANC IYILL�nAINTAIN WOqKERS'CO3dPEN5kTiON INSURANCE,P.5 FEOJIa'cD AY SECTiON (,"?� ry / � 37o00FTHE.ABORCODE.FOHTHEPFRFORMANCEOFTHF.WDRKFORWHICHTHISPERM!715 k G-(� fl �SSUEO.MY WORKERS'COMPENSATION INSURANCF CFRFIER RNO iOL'CY M1M9ER ARE I CONSTSiUCTION ___ _ _______ ____ � _ ___ j CAFtRIER'_ _,____""__'_""'"_ I PLAN RFVIEW _ ' . � - ZPOLICYNUM9�R.__" ___'-_"_'-____"__""""_-__"_"" I ELFCTRIC �� .�_ ��'�---- � ��ssEcnovNE�rnreEmu�FrEvaF�aE�anr�5xaa.ENunnaEox��nrs�xim)ai�Ess; I PLUMBING �_ � ^ . - ICERTIFVTHATINTHEPEqFONMANCEOFTHEWORKFORWFI:CHTHISPEAMITISISS;;FDI I I MECHANICAL __ ________�____ _ ' SHALL NOT[MPLOYMJY PERSON IN ANY MANNEA SO AS TO BECOM[SUB!ECTTO'H£ � � ((� WOflKERS'fbN.PENSATIONLRWSOFCALIFORNIA,ANDAGR'cETHTIFiSF�i::LDBLCOME INSPECTIONFEE ____,_______ .''} r� ' �' SU&IECT TO TNE WORKERS'�MPENSATIDN PqOVISIONS OF 5 ION 3]0o CF TNL_n�OR ���`'� .._ � cooe,i ALL RTHWIh1CCM?I.V WITH7H05 qov oia+� ISSUANCE __.,,,___.__,______ __.,.__._. ! O 1 �- p DATE:� RPPLICANT: _ � SMiF ___ p yj�� LL1 „'.�-� � � l.i�..� — J ENFRGY P!C WARNING: LUR 70£[CUREWORKERS'COMPENSA NCOVE GEISU:�UWFUL,ANC!^uHT�LBE ------- --'�-- �y SUBJECTANEMPLOYERTOCqIMIW1LPENALTIESANOCIVILfME5IP700NEHUN')REDT!i0U5APoD FNtiRGYPERMIT �JOIURS(f111a.a0a).IN ADDITION TO THE CASTOF COMP�NSA710N,UAAAAGE�AS PROVIDED FOR IN -�-------------� --�- J SECTION37oeOF;HELABORCODE.INTEREST,ANDATTOP�[Y'SFEES. 4 ' jy�� � � � _ RETcN710N FEE: ---- ---- c� i'7+�- a�.. CONSTRUCTION LEND!NG AGENCY PRE-AIT F�E:fy -§r7y���q � '� }�n 7� Q IHEREBVAFFIRMUNOERPENALTVOFPERJURVTMATTHEREISACONSTRUCTIDNLENOiNGAGCNCY �__�f"�s� ^- "M""��A`:�i.1�SiYA�I '."a� � FORTHEPERWqMANCEOFTHEWORKFORWHICHTHISPFflMIT15155UE0�5EC?O�7,CIV.C; � � fYa37 , Z � � R �]4,L.�..,�i�i,h;.�C.f'.�a�i�<{�-',�y'"°'.?'�T � LENDER'SNAME__ _'"'__"'___""_____._—'._—'-'_ �����' F- LEHDER'SAbDR'cS5_ � IGEATIFYTHATIHAVFREMTHISAPPLICAiIONANOSTATETHATTh1EABOVEIkFCRMATION�SCOqRECT. TOTP9L��EJ ` � � 1 AGHEETO CAMPLY WITH FLl CRY At�ID COUNTY ORDINA�CES ANO STA7E LAWS RELATING 70 BUILD�NG i dl CONSTFUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES oF THIS COUMY TC ENTEpUPON THE ��,///��� � PBOVE�MENfIOD1EDPROPERTYFORI4SPECTIONPURPO5E5. ���1� ����-"� ��� Q COMMENTS_� .�, � � � //�'l'� ^ ` � --- , _ ----- m PERMITT�N_AM / C ��'- ____ _ � <C � - / - Vy SIGNATUREO 9 _E � DA[ -�_"�-��—'_' _�/j .._ _..+. Z RECPT.NO.__ PRID BY __ VALIDATION__ � � W�.��� WHliE--0epa!tment Copy,YELLOW-Flnence CoDY.PItdK-Assessor Copy,GOLDENROD-File Capy,GREEN-Applicant's Copy °:�" `�tz ;�s�,�`�� .-. fi..�f.,_,e. ..��':�1..b F..�^�"�1 ��:,<p v' "`5.4xY�R.«-���.fr�M.:� ��4 :�`x 4..v^^.�'a _ .yvv .�.... .+....i.>..�....�.:.�xeTS." <SPe;m '�'S� jN,°^ sT": n..�. ...:.�,i SP";� ^�4,3!,W,"*+=^S `�� Y f ) 5. "d; 'c ^'Tt,� s.w �wmn#, � T._ `�:.5 "5y5rss,=s„;iv, w4"Y-.:' „ ����:•��' �� .r� ;c��P� t '� }� �t,ae �� s� � `<�,� �,i � � ..a� ��r# ,� `ta'. 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